'Abnormal Movements' in a 12-Year-Old Boy
'Abnormal Movements' in a 12-Year-Old Boy
A 12-year-old boy with a history of generalized motor delay presented to the emergency department (ED) complaining of "abnormal movements." The patient first noticed occasional jerking movements of his left arm approximately 2-3 weeks ago. He was evaluated in the ED 1 week prior at the recommendation of his family members. He had a recent history of head trauma sustained during karate. CT scan of the head was negative. He denied loss of consciousness or vomiting. His family members stated that his behavior was appropriate after the head trauma. The patient was discharged home with a referral to neurology for an EEG and MRI scan of the brain.
During the following week, his symptoms progressively worsened to involve his mouth and all extremities. The patient reported having some word-finding difficulties in addition to a writing apraxia. He described feeling clumsy and noted changes in his gait. His symptoms seemed to improve after watching TV or sleeping. He denied emotional lability, but his family stated that they found him laughing for no apparent reason 2 days ago. The patient expressed significant distress because of these movements and, as a result, was taken out of school.
The parents denied a recent history of fever, chills, nausea, or vomiting. The patient's only significant medical history was a diagnosis of mononucleosis 2 months ago. He was evaluated by his primary care physician for complaints of fever for 5 days, malaise, and sore throat. His monospot test was positive.
Vital signs: temperature, 37.4°C; heart rate, 96 beats per minute; blood pressure, 124/66 mm Hg; respiratory rate, 20 breaths per minute; weight, 38.3 kg
General: well developed; in no apparent distress, but fidgeting
Head, eyes, ears, nose, and throat: normocephalic; pupils are equal and reactive to light; conjunctivae are normal; no nasal discharge; mucous membranes are moist; tonsils are 3+ bilaterally with no exudates; oropharynx is clear
Neck: supple with normal range of motion
Cardiovascular: regular rate and rhythm; normal S1 and wide splitting of the second heart sound, +2/6 nonspecific systolic, possibly blowing, murmur at the left midsternal border; no gallops, rubs, or thrills; pulses are palpable
Lungs: no respiratory distress; normal breath sounds
Abdomen: full and soft with no distention, tenderness, rebound, or guarding
Musculoskeletal: normal range of motion; no deformities or injuries
Neurologic: alert; normoreflexic with a Glasgow Coma Score of 15; cranial nerves II-XII are intact; rare minimal movement of low amplitude of the shoulders when walking or running; chaotic, purposeless movements of the upper extremities and hands; the palate elevates equally; the tongue protrudes to midline, but patient has difficulty maintaining tongue protrusion; speech is fluent and coherent
Skin: warm; capillary refill less than 3 seconds; no petechiae, purpura, rashes, jaundice, or pallor
Physical examination findings were consistent with choreiform movements; therefore, neurology was consulted for evaluation of the patient in the ED.
Case Presentation
A 12-year-old boy with a history of generalized motor delay presented to the emergency department (ED) complaining of "abnormal movements." The patient first noticed occasional jerking movements of his left arm approximately 2-3 weeks ago. He was evaluated in the ED 1 week prior at the recommendation of his family members. He had a recent history of head trauma sustained during karate. CT scan of the head was negative. He denied loss of consciousness or vomiting. His family members stated that his behavior was appropriate after the head trauma. The patient was discharged home with a referral to neurology for an EEG and MRI scan of the brain.
During the following week, his symptoms progressively worsened to involve his mouth and all extremities. The patient reported having some word-finding difficulties in addition to a writing apraxia. He described feeling clumsy and noted changes in his gait. His symptoms seemed to improve after watching TV or sleeping. He denied emotional lability, but his family stated that they found him laughing for no apparent reason 2 days ago. The patient expressed significant distress because of these movements and, as a result, was taken out of school.
Medical History
The parents denied a recent history of fever, chills, nausea, or vomiting. The patient's only significant medical history was a diagnosis of mononucleosis 2 months ago. He was evaluated by his primary care physician for complaints of fever for 5 days, malaise, and sore throat. His monospot test was positive.
Physical Examination
Vital signs: temperature, 37.4°C; heart rate, 96 beats per minute; blood pressure, 124/66 mm Hg; respiratory rate, 20 breaths per minute; weight, 38.3 kg
General: well developed; in no apparent distress, but fidgeting
Head, eyes, ears, nose, and throat: normocephalic; pupils are equal and reactive to light; conjunctivae are normal; no nasal discharge; mucous membranes are moist; tonsils are 3+ bilaterally with no exudates; oropharynx is clear
Neck: supple with normal range of motion
Cardiovascular: regular rate and rhythm; normal S1 and wide splitting of the second heart sound, +2/6 nonspecific systolic, possibly blowing, murmur at the left midsternal border; no gallops, rubs, or thrills; pulses are palpable
Lungs: no respiratory distress; normal breath sounds
Abdomen: full and soft with no distention, tenderness, rebound, or guarding
Musculoskeletal: normal range of motion; no deformities or injuries
Neurologic: alert; normoreflexic with a Glasgow Coma Score of 15; cranial nerves II-XII are intact; rare minimal movement of low amplitude of the shoulders when walking or running; chaotic, purposeless movements of the upper extremities and hands; the palate elevates equally; the tongue protrudes to midline, but patient has difficulty maintaining tongue protrusion; speech is fluent and coherent
Skin: warm; capillary refill less than 3 seconds; no petechiae, purpura, rashes, jaundice, or pallor
ED Course
Physical examination findings were consistent with choreiform movements; therefore, neurology was consulted for evaluation of the patient in the ED.
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